Basic Information
| Provider Information | |||||||||
| NPI: | 1578224390 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIBERTY DIALYSIS SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4336 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | BELLBROOK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453051551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372961550 | ||||||||
| FaxNumber: | 9372961540 | ||||||||
| Practice Location | |||||||||
| Address1: | 4336 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | BELLBROOK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453051551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372961550 | ||||||||
| FaxNumber: | 9372961540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2022 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | CARPENTER | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9372961550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2472R0900X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Technician, Other | Renal Dialysis |
No ID Information.